One care journey. Three torn systems.

Cohezon. A Care Continuum platform built to connect what no single EHR can: hospitals, post-acute providers, primary care, and the patients moving between them.

Founded by healthcare leaders. Built with the RN case managers brought in before writing a single line of code.

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A patient, nurse, and family member across three torn photo strips, showing fragmented coordination between hospitals, post-acute providers, and primary care.

That tear has a cost. And fixing it has a deadline.

Effective 1/1/26, CMS TEAM (Final Rule CMS-1808-F) raises the stakes for hospitals that don't coordinate care.

Care Transition

23.3%

Return to the hospital, or worse¹

Nearly one in four patients discharged to a skilled nursing facility is readmitted or dies within 30 days.

Care Coordination

$4,500

Higher cost per fragmented patient²

Chronically ill patients whose care is scattered across providers cost thousands more and hit more quality gaps.

Patient Navigation

60%

Understand their post-discharge plan³

Only three in five patients grasp what happens after they leave. The rest are guessing.

1 - Neuman et al., JAMA, 2014
2 - Frandsen et al., American Journal of Managed Care, 2015
3 - Horwitz et al., JAMA Internal Medicine, 2013

Today's tools each only fix one slice.

Every tool here owns one piece of the handoff. EHRs document inside a single organization. Referral platforms shuttle packets between inboxes. Navigation apps hand patients information with no clinical context.

The patient moves through all of them.

A clean minimal flat graphic on a white background Large bold text in navy blue 0d1f3c reads 52 centered and dominant Below it smaller text in navy bl-2

The unnecessary costs after medical discharge

Case managers still depend on chat, institutional knowledge, and faxes.
30% of post-acute referrals require follow-up, taxing staff resources.
20% of hospital bed days are avoidable, costing $2,800 per day.
Families are left in the dark, unsure where to turn next.

Meet Cohezon.

Cohezon is the care continuum layer that sits above all of it. The patient moves through every setting. Cohezon moves with them, so hospitals discharge faster, post-acute gets complete referrals, primary care stays in the loop, and families always know what's next. One foundation, by design, not integration.

Two Assistants. One Platform.

One platform. Two assistants: Dina for the people coordinating care, Mena for the people living it.

A unified engine will always outperform a collection of tools trying to stay in sync.

Discharge Navigation Assistant

The interface for case managers, post-acute providers, and primary care. Dina replaces faxes, phone tag, and tribal knowledge with one shared workspace where every handoff is visible and nothing stalls waiting on a callback.

Member Navigation Assistant

The interface for patients and families. Mena gives patients and caregivers clear choices and plain language, at the bedside, at home, or before admission, so they can take part in decisions when they're being made, not after.

Already validated.

Cohezon is running in real hospitals ahead of any formal pilot, saving ~1 bed day per case manager per week.

DiMe

"It is rare to find partners who are as clear-eyed about the realities of healthcare, and who are thinking creatively about what it will actually take to meet patient and clinician needs."

— Digital Medicine Society (DiMe)

Design Partners

8 post-acute organizations signed as design partners across skilled nursing, home health, home care, hospice, and senior placement agencies.

From the field

"Dina:Clear is an innovative tool that helps patients discover nearby facilities like ours that they might otherwise miss and reduces avoidable bed days by revealing these 'hidden gems.'"
- Ian Cook, Business Development, Moraga / Rossmoor / Tice Valley Post Acute

"Dina:Clear makes it easier for hospitals to connect patients with the right hospice care, faster. It's helping us build relationships and serve families when timing and compassion matter most."

- Jose Fernandez, Sonata Hospice

You've seen the proof. See the platform.